ENGAGING WITH MEN TO IMPROVE THEIR HEALTH

A toolkit for the voluntary sector

Contents

Section 1: Introduction.............................................................................................. 4 Section 2: What is the current state of mens health? ........................................... 5 Section 3: What can we do to improve mens health?........................................... 14 Section 4: Working at a grassroots level to improve mens health ..................... 23

About this toolkit

This toolkit is designed for those who work in the voluntary and community sector to: I Provide an overview of the current state of mens health I Raise awareness of why it is important that we work to address mens health issues I Explore ways to engage with men to improve their health.

About the Mens Health Forum

Who we are
I MHF is the voice for the health and wellbeing of men and boys in England and Wales.

Why we exist
I Our goal is the best possible physical and mental health and wellbeing for all men and boys. There is one premature male death every five minutes and far too many men and boys suffer from health problems that could be prevented.

What we believe
I There is an urgent need to tackle the unnecessarily and unacceptably poor health and wellbeing of men and boys. I The health of the whole population should be improved through an approach that takes full account of the needs of both sexes. I Men and boys should be able to live healthy and fulfilling lives, whatever their backgrounds.

What we do
I Listen to and represent the concerns of men and boys. I Support men and boys to improve their own health. I Campaign for changes that will make a difference to men and boys, especially in those communities where the problems are greatest. I Collaborate with the widest possible range of organisations and individuals, nationally and locally. I Provide information, resources and training to equip agencies and professionals to deliver services to men and boys. I Develop local community networks of professionals and volunteers. I Accelerate research. I Promote equality and diversity in every aspect of our work. In 2009, we became a strategic partner of the Department of Health. This three-year programme involves us working alongside government to help the NHS and voluntary sector organisations improve the health of men and boys. The Men's Health Forum (England and Wales) is a registered charity (No 1087375).

1. Introduction
Why does the voluntary sector have such an important role to play in improving mens health? Unfortunately mens health in this country still lags far behind the health of women. We know that a major strength of the voluntary sector is engaging with seldom heard and hard to reach groups. In the area of health, we believe that men fit in this category. The voluntary sector has much to offer in helping to improve mens health. Voluntary and community organisations come into contact with a range of men, often outside of traditional health settings. These circumstances offer lots of opportunities to raise awareness of health issues in settings that are familiar and comfortable to men. They also present a chance to signpost men to appropriate sources of health advice and information. Why is improving mens health important to the voluntary sector? 42% of men currently die prematurely (before the age of 75). Helping to improve mens health allows men to be more healthy active citizens, who can play a meaningful role in their communities for longer. Government health policy now places significant importance on reducing health inequalities, and the NHS Commissioning Board has a statutory duty to address health inequalities. The NHS Outcomes Framework and the Public Health Outcomes Framework both place an emphasis on reducing health inequalities and preventing premature death. These policies are likely to have a consequent impact on the outcomes that Local Authority and NHS commissioners require voluntary sector organisations to meet. Working to improve mens health offers an excellent opportunity to reduce inequalities, given that men (especially those from socioeconomically disadvantaged backgrounds) experience health inequalities and premature death at a disproportionately high level (see Section 2 for further details).

Mathias Wilson / istockphoto.com

2. What is the state of mens health?

So, why are we making a fuss about mens health? Well, the evidence is quite stark regarding the current state of mens health.

A brief overview
I The average life expectancy for baby boy born in 2008-10 is 78.4 years compared to 82.4 years for a baby girl, a difference of 4 years. I Premature death mainly affects men. 42% of men die prematurely (before the age of 75) from all causes compared to 26% of women. 21% of men aged 16-64 die from all causes compared to 12% of women. I Unskilled manual men have an average life expectancy of 73 and, in some parts of England, male life expectancy is as low as 65. The mortality rate of men in routine and manual occupations is 2.3 times that of men in managerial and professional occupations. I The social gradient has a greater impact on mens health than womens the life expectancy gap between men and women widens as deprivation increases. I Coronary heart disease kills more men than women and on average men develop it 10-15 years earlier. South Asian men living in the UK have an even higher premature death rate from heart disease and stroke than men generally. I Men are 60% more likely to develop and 70% more likely to die from a cancer that should affect men and women equally (i.e. excluding breast cancer and the sexspecific cancers). I Men are more likely than women to drink alcohol above recommended levels, smoke cigarettes and eat a poor diet. I Almost one third of boys are now overweight or obese. By 2015, 36% of men will be obese (compared to 28% of women) and, by 2025, only 13% will have a healthy body mass index (compared to 25% of women). I Three times as many men kill themselves. The suicide rate for men is much higher in deprived areas. Young gay men are more likely than heterosexual young men to attempt suicide. I Black and ethnic minority men are less likely to seek help for mental health problems. I Men use the range of primary care services far less than women and, crucially, take longer to present and receive a diagnosis. I Men are slightly more likely than women to use Accident and Emergency Services. However, in the age-group that makes by far the most use of A&E, 20-29 year olds, men are in a significant majority. I NHS smoking cessation programmes are less well used by men than women as are weight management services and health trainers.

Current State of Mens Health: the main issues

Dying young
Almost 100,000 men are dying prematurely (before 75 years) each year compared to about 66,000 women.1 By comparison, Wembley Stadium has a capacity of 90,000 and the British Army has 102,000 full-time personnel.

22%

of men die before the age of 652

42%

of men die before the age of 753

Life expectancy at birth4 & 5

Men

77.4 UK 77.7

England

Women

81.6 UK 81.9

England

Men and health services

Men visit the GP 20% less than women.6
I Men are generally poor users of primary care, especially younger men who visit the GP half as often as younger women. I Women have higher GP consultation rates for a wide range of illnesses, so the gender differences cannot be explained simply by their need for contraceptive and pregnancy care. Women also continue to visit the GP more than men through their 40s and 50s.7 Men are also less likely to access other health services such as dentists, pharmacists, health trainers, smoking cessation services, weight management and contraception services. I Men use hospital A&E departments more often than women. I 52% of all hospital A&E department visits are by men. Men aged between 20 and 29 years are the biggest single group of users of A&E departments.8
1. Office for National Statistics (2008), Mortality Statistics: Deaths registered in 2007 Review of the National Statistician on deaths in England and Wales. . 2. Office for National Statistics, Interim Life Tables 2006-8 3. ONS, Life expectancy at birth and at age 65 by local areas in the United Kingdom, 2006-08 4. ONS, Trends in Life Expectancy by social class 1972-2005, October 2007 5. ONS, Health Statistics Quarterly 47 Autumn 2010 , 6. General Lifestyle Survey 2008, chapter 7 7. Bajekal M. et al (2006), Focus on Health

8. NHS Information Centre, Hospital Episode Statistics: Accident and emergency attendances in England (experimental statistics), 2008-09

Izabela Habur / istockphoto.com

MORE INFORMATION Central to the work of the MHF is mens poor use of a wide range of primary care services. Men often delay seeking medical help until conditions have become more advanced and harder to treat this is thought to be a factor behind mens high death rates from cancer and other conditions. The Forum has completed a range of work on this issue. The Gender and Access to Health Services Study (2008), commissioned from the MHF and published by the Department of Health, examined the different ways women and men use a variety of key services. In 2009, we published the Racks of make up and no spanners report on mens use of pharmacies. There is information on access to services on malehealth, the MHF's health information site for men of all ages. There is also an excellent section on understanding health statistics.

Mental health

76%

of people who kill themselves are men9

73%

of adults who go missing are men10

I Men make up 94% of the prison population.11 72% of male prisoners suffer from two or more mental disorders.12 MORE INFORMATION Our work on mental health includes Untold Problems (2010), a review of the major issues in male metal health, and Mind Your Head (2006). In 2011 we worked with leading mental health charity Mind to publish Delivering Male, a guide for mental health professionals on working with men. There is information on men's mental health issues on malehealth, the MHFs health information site for men of all ages. There is also an excellent section on understanding health statistics.

Cardiovascular disease
This is the most common cause of death in men.13

300 per 100,000

Male death rates from circulatory disease*

*includes heart disease and strokes

190 per 100,000

Female death rates from circulatory disease

9. ONS, Suicide rates in the UK 1991-2008 10. Biehal N, Wade J and Mitchell F Lost from view: Missing persons in the UK. Bristol: Policy Press; 2003 . 11. Ministry of Justice. Population in custody: Monthly tables, March 2009. England and Wales. London: Ministry of Justice; 2009 12. Social Exclusion Unit. Mental Health and Social Exclusion. London: Office of the Deputy Prime Minister; 2004 13. ONS, Mortality: Circulatory diseases - leading cause group, January 2006

Cancer
Men are 70 per cent more likely than women to die from cancers common to both sexes and 60 per cent more likely to get these forms of the disease.14
I Between 1983 and 2007 the rates of oesophageal cancer in men rose by 50% and in women by 8%. Changing diets and obesity are thought to be the cause.15 MORE INFORMATION Our work showing mens disproportionately high rates of cancer was launched in National Mens Health Week in 2004. In 2009, we collaborated with leading cancer organisations to publish The Excess Burden of Cancer in Men in the UK.

Slow on the uptake? our major government-funded study looking at how to improve mens uptake of the national bowel cancer screening programme, was published in 2011.
There is information on all these health condition on malehealth, the MHFs health information site for men of all ages including heart disease and cancer. There is also an excellent section on understanding health statistics.

Lifestyle
Weight and activity16

41%
of men are overweight

38%
of women are overweight

I Forecasts show that, by 2020, 80% of men will be overweight or obese.17 I Just 40% of men meet the Chief Medical Officers recommendations for physical activity. I Activity levels fall sharply with age. About 50% of men aged 16-34 say they meet the recommendations but the levels decline to 44% for 35-44 year olds, 32% for 55-64 year olds and 9% for men aged 75 or over.18 I In England and Wales, one million more men aged 35-64 years need to be more active for the same proportion of this age group to be as active as younger men.

14. National Cancer Intelligence Network et al, The Excess Burden of Cancer in Men in the UK 15. Cancer Research UK, Oesophageal cancer - UK incidence statistics, August 2010 16. NHS Information Centre, Statistics on obesity, physical activity and diet: England, February 2009 17. A prediction of Obesity Trends for Adults and their associated diseases. Analysis from the Health Survey for England 1993-2007 McPherson K, . Brown M, Marsh T and Byatt T. (2010). Available to download from http://www.heartforum.org.uk/ 18. NHS Information Centre, Health Survey for England 2008: Volume 1. Physical activity and fitness

Tomazl / istockphoto.com

Drinking and smoking:

I 33% of men and 16% of women are drinking at a potentially harmful level. This includes the 6% of men and 2% of women estimated to be harmful drinkers, which means that damage to health is likely. I Between 1992 and 2008, alcohol-related death rates in men more than doubled, rising from 8.2 per 100,000 to 16.7 per 100,000.19 I Men are more likely to smoke than women 22% compared with 19%. 16% of men in non-manual work smoke compared with 27% in manual work.20

MORE INFORMATION The MHFs policy paper Hazardous Waist: Tackling the epidemic of excess weight in men (2005) focused on the increasing levels of obesity and weight problems in men and how understanding gender differences is important in tacking them. In National Mens Health Week 2010, MHF launched the One Million More Men Challenge. This aims to get one million men aged 35-64 more physically active. There is information on all these issues on malehealth, the MHF's health information site for men of all ages including weight-loss, exercise, smoking and drinking. There is also an excellent section on understanding health statistics.

Mens symptom awareness

Men demonstrate poorer symptom awareness and reporting than their female counterparts. We know that middle-aged men are twice as likely to have diabetes as women and that men are twice as likely to not know they have diabetes. Similarly, when we compare incidence and mortality rates for melanoma, we can see that although men are less likely than women to have a melanoma, they are more likely to die from the condition.21

19. Office of National Statistics, Alcohol-related deaths in the United Kingdom, January 2010 20. NHS Information Centre, Statistics on Smoking: England, 2009. September 2009 21. Tackling the excess, incidence of cancer in men. Wilkins, D. (2007)

Alex Potemkin / istockphoto.com

Mens poor health: a fundamental inequality?

In the last section we highlighted the differences between male and female life expectancy. However, if we delve deeper we can see that there is a fundamental inequality at play in mens poor health. Life expectancy for men is inextricably linked to social class and deprivation. The gradient for this link is steeper for men than it is for women.

Top ten UK & English local authority areas for male life expectancy at birth 22
Kensington and Chelsea Westminster Fareham, Hampshire Hart, Hampshire Elmbridge, Surrey South Bucks East Dorset Epsom and Ewell, Surrey Wokingham, Berkshire South Cambridgeshire 84.3 82.9 81.4 81.3 81.3 81.2 81.2 81.2 81.1 81.1

Bottom ten English local authority areas for male life expectancy at birth 23
Blackpool Manchester Liverpool Sandwell, West Midlands Blackburn with Darwen Corby, Northamptonshire Salford Halton, Cheshire Kingston upon Hull Islington 73.6 73.8 74.3 74.3 74.4 74.4 74.5 74.8 75.0 75.1

Top ten UK & English local authority areas for male life expectancy at birth

Bottom ten UK & English local authority areas for male life expectancy at birth

22. Office of National Statistics, Life expectancy at birth and at age 65 by local areas in the UK, 2006 2008 23. Office of National Statistics, Life expectancy at birth and at age 65 by local areas in the UK, 2006 2008

10

YM German / istockphoto.com

Life expectancy at birth by social class 24

I II IIIN IIIM IV V Unclassified 80.0 85.1 79.4 83.2 78.4 82.4 76.5 80.5 75.7 79.9 72.7 78.1 73.8 77.9
Men Women

Mortality rates in England and Wales by three social classes, men aged 2564 25
407 Mortality per 100,000 297 178 Mangerial & professional Intermediate Routine & manual

24. Office of National Statistics, Trends in life expectancy by social class 1972 2005 (October 2007) 25. Office of National Statistics, Health Statistics Quarterly 47 Autumn 2010 ,

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Gary Sludden / istockphoto.com

This pattern is also shown in deaths by suicide, cardiovascular disease and cancer the conditions responsible for the greatest proportion of premature deaths in men, as shown in the following graphs:

Suicide rates by deprivation and gender (England and Wales 1999 2003) 26
Age-standardised rate per 100,00 population (aged 15 and over)

30

25

Men

20 England and Wales rate 15

10 Women 5 England and Wales rate

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Deprivation twentieth Least deprived Most deprived

Circulatory disease rates in under 75s by deprivation level, 1999 and 2001-2003 27
250

Rate per 100,000 population

200

150

100

50

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Deprivation twentieth Least deprived Most deprived

Men

Women

26. Office of National Statistics (2006) Suicide trends and geographical variations in the UK Health Statistics Quarterly 31, Figure 7/Autumn 2006 27. Office of National Statistics Health Statistics Quarterly

12

Cancer rates in under 75s by deprivation level, 1999 and 2001-2003 28

250

Rate per 100,000 population

200

150

100

50

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Deprivation twentieth Least deprived Most deprived

Men

Women

Lifestyle
As we saw in the last section, men are more likely than women to engage in risky lifestyle behaviours. The table below shows the rate of admissions to hospital for alcohol related incidents correlates directly with levels of deprivation. It is clear that there is a long way to go until men achieve the optimum level of health in this country. However, there are lots of positive actions that can be taken to improve mens health, which we will explore in the next section.

Alcohol-attributable hospital admissions by deprivation, England 2006-7 29

2500
Age-standardised rate per 100,00 population

2000

1500

1000

500

0 Least Fourth Third

Deprivation level

Second

Most

Men

Women

28. Office of National Statistics Health Statistics Quarterly 29. NHS Information Centre Hospital Episode Statitics

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3. What can we do to improve mens health?

A starting point
The question we are asked most frequently usually goes something like this: But men arent interested in improving their health, how can you change that? Its quite nice to be able to have a conversation that starts with Well actually men are interested in their health and theres quite a lot we can all do to help improve it. A good starting point is asking ourselves the question how do we think about mens health? Take a look at both of the diagrams below:

Service providers have little enthusiasm for meeting mens specific needs

Men seem a dispiriting, expensive and time-consuming target group

Service providers recognise the need and feel positive about the challenge

Men are a responsive and rewarding target group

14

Men are motivated about their personal health

Men will use health services and take part in public health programmes

Men are less likely to use health services or take part in public health programmes

Men are less motivated about their personal health

The two diagrams represent a challenge to how we think about mens health and the preconceptions we can bring to our thoughts about it. Which of the diagrams is closest to the way you think? You could argue that this oversimplifies a complex issue and you would be right, but it does illustrate that our preconceptions can have a profound influence on how we approach working with men and talking about health matters. It is important to be aware of these biases that we all have and to try to challenge them in our own work with men.

The problem is clear but what about some solutions?

What works and what we think might work
We have established that improving mens health in this country has a long way to go. In the following sections we draw together some of the best ideas on how to engage with men, based on our own experiences and the experiences of others that work to improve mens health.

Male-friendly environment
This idea might seem obvious but in fact it is often overlooked. Establishing a male friendly environment provides the grounding for everything else that works to engage men. For example, community centres and primary care health services (such as the GP and Pharmacies) can often be designed primarily with women in mind. A quick scan of the posters and information leaflets available, often reveals a very female orientated environment, which can be unwelcoming for men. Many GP surgeries have taken steps to address this to good effect. You can avoid this in your services and interactions with men by considering the environment and including items, such as posters, leaflets and activities (if appropriate) that target men.

Going where men are

We know that men do not access traditional buildings based services in the same way as women. An example of this, is the fact that men attend their GP surgery 20% less than women over the course of the year. We often hear that men are hard to reach but there are many places where men are hard to avoid! Some of the most effective ways of engaging with men come from going to where men already are, and where they feel comfortable. There are a number of examples of health promotion events that have been carried out very successfully at football and rugby stadiums and pubs.

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CASE STUDY

Leeds Rhinos and Leeds Metropolitan University

In 2009, Leeds Metropolitan University began an innovative collaboration with Leeds Rhinos Rugby Club, to improve the health of supporters attending home matches at Headingley Carnegie Stadium. For each Rhinos home match the Leeds Met team attended and offered supporters free screening checks and delivered health promotion messages at the stadium on match days.

CASE STUDY

BT Work Fit
In partnership with MHF BT developed a pioneering intranet-based lifestyle change programme , (Work Fit) for its workforce that attracted over 16,000 users, most of whom were men. There is good evidence that Work Fit produced significant behaviour change among participants: it was possible to track about 5,000 participants over the 16-week programme and the average weight loss (the main indicator of compliance) was 2.3kgs. A six-month follow-up survey found that a majority of those who lost weight either maintained the weight loss or lost more weight. This is a very encouraging outcome for a mass participation programme.

Key points to consider: I Outreach works very well for men I Consider your service setting, make men hard to avoid rather than hard to reach I Make the most of community settings where other voluntary groups/statutory services are often happy to allow you to use space I The workplace offers an excellent setting through which to target men

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Presenting health information in a variety of male targeted formats

Despite mens often reluctant engagement with traditional health services, most men do still care about their health and do respond to messages when the information is presented in formats that appeal to them. We know that men are enthusiastic users of wide range of digital technologies online systems, mobile phone applications, social networking, gaming, etc. 80% of men used the internet in the last three months (National Statistics data for 2009). 99% of Pre-Family Men say they go online every day or nearly every day, according to Microsoft research, and 50% of them use their mobile phones to go online. We know that many men feel comfortable using the internet to access health information. Men have expressed their desire to access information and health advice anonymously and confidentially. Using the internet provides a very obvious way to do this. For community organisations that already have websites, it is worth considering signposting men to health information through this. CASE STUDY

Malehealth website
The malehealth website has been designed with a consumer focus. It aims to provide free, independent and credible health advice in an accessible format for the man on the street. It covers a range of health topics including common conditions that men may find embarrassing to discuss, such as erectile dysfunction and prostate problems. The site has over half a million unique page views a year and has won a BMA Patient Information Award for its work in engaging male patients. The Men's Health Forum's consumer website (www.malehealth.co.uk) attracts 1.8m unique visitors a year. 70% of respondents to a malehealth survey in 2009 said the internet was their first stop for health information mainly because it was quick, private and free. The most heavilyused sections of the site concern issues which many men find embarrassing to talk and ask for help about (e.g. urological or sexual health problems). Lloyds pharmacys Online Doctor has also reported that the men using its service consult for similar concerns.

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CASE STUDY

Man MOT
Man MOT (www.manmot.co.uk) is the UKs first online surgery for men. It was created as statistics show that men are less likely to visit their GP than women if they have a health concern and can often worry about wasting their doctors time, but by not seeing a GP serious , health conditions could be going undetected and undiagnosed. GPs can talk to men about any health problem, suggest the best course of action to take, and direct you to appropriate health services if needed. In addition to more general health clinics with GPs, specialist sexual health and relationship sessions are hosted by sex and relationship expert Tracey Cox and Relate counsellors. Man MOT is funded by Pfizer and supported by Diabetes UK, Family Planning Association, HEART UK, Men's Health Forum, National Obesity Forum, Relate and Sexual Advice Association. Man MOT attracted 15k visitors in the 3.5 months up to mid-November 2010 but, more significantly, enabled 341 men to have a live consultation with a GP or another health specialist on Monday evenings.

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Steve Debenport / istockphoto.com

Paper based male-targeted information

Men and women respond differently to health information resources. Gender sensitive health information (i.e. information targeted for men and women) can have a far greater impact than generically produced information. At the MHF we have been producing a range of manuals in the style of the Haynes car manuals, targeted specifically at men for the past 15 years. They have been independently evaluated and well received by those who commission them.

CASE STUDY

Yorkshire Man Mini manual

The Yorkshire Man mini-manual was put together with the Department of Health Yorkshire and Humber, the NHS and Leeds Rugby. Designed specifically to target men in Yorkshire to raise awareness of health issues, it was laid out in a clear, easy-to-read style and targeted directly at men in the area. The guide formed part of the Tackling Men's Health partnership between Leeds Met and Leeds Rhinos, which delivered health promotion messages and screening for fans at Headingley Carnegie Stadium on match days. Jane Riley, Associate Director of Public Health for the Yorkshire and Humber region, commented on the manual: The Yorkshire Man guide has been written for men of all ages right across the region. We know that Yorkshire men are proud of their region and their reputation for working hard, doing well and having fun: whether it's at work, with their families or on the sports field. The guide linked to further sources of information including the NHS and a range of high quality websites and guidance, including the website, Yorkshire malehealth, provided by the MHF It has . been awarded the Crystal Mark by the Plain English Campaign and was highly commended in by the BMA. An independent evaluation of the manual by Leeds Metropolitan University confirmed its positive reception by men, rating it as useful and very useful.

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Humour
Humour can be a valuable tool to conveying serious health messages to men, in a less formal manner. Humour can provide a means to provide serious health promotion messages, while still maintaining a light hearted tone that is often appreciated by men.

CASE STUDY

Coventry City Council

Coventry City Council has worked with comedian John Ryan to break down the barriers that stop men from accessing health services and improving their lifestyles. His act is designed to break down some of the taboos associated with male health problems. He uses a range of jokes to do this, and before and after his act, drinkers are offered health MOTs, including blood glucose and cholesterol checks, and lifestyle advice by a team health professional. Those who have taken part are full of praise. One participant who saw the act in an Irish pub said:

The way the comedian raised the issues of health through humour was fantastic. His understanding was a tremendous help. It really brought home that we as men need to start taking responsibility for our health and not leave it till it is too late. Tackling health in this innovative way was very good in making everyone feel comfortable and not embarrassed.
As well as pubs and working mens clubs, the sessions have also taken place at the fire service and at the annual general meeting of the Coventry Irish Society. The comedy sessions are just one of a number of tailored projects that have been overseen by the councils health development unit since it started the focus on mens health in 2004.

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Obstacles and Solutions

Some of the most common obstacles that are mentioned in working on mens health are highlighted in the table below, along with some possible solutions.

Obstacles
Men use services less effectively Men take less notice of health messages Not enough known about male attitudes and behaviours Not enough known about how to work with men Men are hard to reach Its mens own fault

Solutions
Review and change services if necessary Change messages Develop research

Develop good practice

Ask if this is really true! Change male attitudes?

What do you think about these solutions? Are they realistic? What are the main obstacles that you have experienced in working with men?

Steve Debenport / istockphoto.com

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Dos and donts when working with men

I Do treat men as individuals. I Do aim to create a male-friendly environment in your group/service/venue. I Do ask men what they want, it seems obvious but lots of service planning and delivery for men is based on assumptions rather than grounded in what the target group have said they want and need, the results might surprise you! I Do target any information that you produce so that it is relevant and straightforward for your target group. I Do think about how you format the information and how men will access it. Many men express the desire to be able to access health information anonymously and confidentially. I Do explore how you can use non-health events to raise awareness of health issues e.g. sporting/social events. Do raise health issues in the context of other activities e.g. as an add on to a sports event. Check out our best practice portfolio for details of mens health interventions that have taken place at football stadia and in pubs. I Do assume that men will be interested in their health if the information is targeted and relevant, questioning negative preconceptions is important. I Do not underestimate how humour can provide a means to mediate more serious health issues. Again see our best practice portfolio for details of projects that have used humour. I Do be prepared to move outside traditional group or service settings and go where men are: pubs, sports events, bookies etc. I Do encourage spouses/partners/friends and family to talk to the men in their life about health issues. This can often spur men into action. I Do be prepared to signpost men to health information on the internet. Even if they do not seem interested now, they might refer to the information later.

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4. Working at a grassroots level to improve mens health

Establishing a local forum to work towards improving mens health in your area
In order to improve the health of men in your area, it might be useful to think about bringing together like minded people, such as others from within the voluntary sector as well as the statutory and private sectors to form a local mens health forum. The aims and subsequent activities of the group should reflect the individual wants and needs of members. Here are some questions to consider, if you are interested in developing your own mens health group.

What are the main men's health needs in your area?

Would any of these groups be prepared to host a men's health group/ sponsor meeting space?

Consider an initial meeting of interested parties

Which groups of men are most at risk of poor health?

Are there any private sector organisations with an interest in men's health e.g. large employers with a male workforce?

Use the meeting to draw up the aims and objectives of the group

Are there any existing voluntary or community groups or services that target men in particular?

Are there any statutory services that work specifically with men?

Draw up terms of reference and an action plan for the group

Where is the greatest need?

It is important to have a good understanding of where the greatest needs lie in terms of mens health. The joint strategic needs assessment should help with this, but should be considered in conjunction with any other locally produced strategy and mapping documents, to build up as complete a picture as possible. Public health data and other information reported by statutory and voluntary organisations around mortality rates from various conditions will also be important here.

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Engage key stakeholders

It is important to engage with other stakeholders who might also have an interest in mens health. Many organisations may inadvertently be working to improve mens health through their existing activities. It is important to consider statutory organisations within the NHS and local authority as well as other voluntary and community organisations and umbrella bodies, such as the local CVS. Other private sector organisations such as employers, football/rugby clubs and the local Chamber of Commerce, may also be interested stakeholders in mens health. The best starting point for this is the local community and voluntary infrastructure organisations, NHS public health and communications departments and the Councils health and communities sections. Once these contacts have been identified it is advisable to ascertain what they would like to get from working together and what they see as the main issues affecting mens health. They are after all the experts and those who will know most about their own area. It is important to keep good lines of communication open after these initial discussions.

Setting up the group

Once the key stakeholders have been identified, it is useful to bring everyone together to discuss the aims and objectives of the group, to decide chairing responsibilities, draw up terms of reference and to begin considering the actions that the group will take.

CASE STUDY

Mens Health Forum in Greenwich

The Greenwich Mens Health Forum was established in 2009, by a number of parties in the London Borough of Greenwich that all shared an interest in mens health. At the time, men in Greenwich had the lowest life expectancy of men in London. The main aim of the group was to co-ordinate actions to improve the health of men in the area. The group was convened and chaired by the Healthier Communities team within the local council, with representatives from local community and voluntary sector groups, NHS organisations (including the Deputy Director of Public Health), local employers and the local Chamber of Commerce. The group drew up terms of reference, which included an agreement to develop an action plan to improve mens health in the area, allowing each member of the group to include actions that they could complete in the course of their own work, as well as joint actions that the group as a whole could work towards.

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Influencing local policy to take account of mens health

The Health and Social Care Act (2012) ushered in a host of changes in local health structures and governance. These changes can present important levers to improve mens health at a local level. Within the new structures, the Joint Strategic Needs Assessment will be key, in deciding the types of services to be commissioned at a local level. Here, we outline how this can be used to improve mens health.

What is the JSNA?

The JSNA stands for Joint Strategic Needs Assessment. The JSNA aims to collate information on the needs of a local population in order to: I identify the major issues affecting the local population regarding health and wellbeing I and the actions to be taken to address these issues. The JSNA came into being as a result of the Local Government and Public Involvement in Health Act (2007). This Act placed a duty on local authorities and PCTs to undertake Joint Strategic Needs Assessments (JSNA). This duty came into effect on April 1st 2008. It was designed to specifically improve the way in which local information on need, is used to inform service planning. Guidance released in December 2007 specified that JSNA as a process should: I identify the current and future health and wellbeing needs of the local population over both the short term (three to five years) to inform the Local Area Agreement and PCT Strategic Plan, and over the longer term (five to ten years) to inform future planning, lead to agreed commissioning priorities that will improve health and wellbeing outcomes and reduce health inequalities I be underpinned by: partnership working; community engagement I identify relevant best practice, innovation and research to inform how needs will best be met I be a continuous process. The findings of JSNA should be owned by the PCT, the Local Authority and the Local Strategic Partnerships, including the health and well-being partnership or its equivalent. The findings of JSNA should feed strategic priority setting, the sustainable community strategy, and the identification of health and well-being priorities for the Local Area Agreement (LAA).

JSNA and improving mens health outcomes

The principles for JSNA clearly lend themselves to working towards better health outcomes for men. We know that men still experience vast health inequalities. The current life expectancy for men in the UK is 78.4 years at birth, compared to 82.4 years for their female counterparts. In many local areas the discrepancies are far greater. For example, in East Glasgow men have an average life expectancy of just 54 years. Men also experience vastly poorer outcomes across a range of health conditions (e.g. cancer) when compared to women. Another area of concern is mens access to health services. Overall, men in Great Britain visit their GP four times a year compared to six times for women. The JSNA offers a unique opportunity for voluntary sector organisations to address these health inequalities on a local level. The JSNA specifically aims to identify key areas for change e.g. health outcomes that are not being met, health inequalities to be addressed, client groups with unmet needs and services that require change.

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Regarding health and wellbeing, men from a range of backgrounds are often amongst those with unmet needs and those at most risk of experiencing health inequalities. The JSNA is an opportunity to remedy this, by taking into account the local needs of men with poor health outcomes, and targeting commissioning and service planning accordingly.

Role for the voluntary sector

There is a clear role for the voluntary sector in helping to inform and influence the JSNA process, particularly in addressing mens health issues. The JSNA should be undertaken across all the relevant organisations in a locality, to produce a joined-up assessment of need. The voluntary sector plays an important role here, in putting forward the voice of the local population. The JSNA is a unique opportunity for voluntary sector organisations to shape the local agenda for health and well being. The voluntary sector already has a vast array of skills and experiences to help to inform JSNA: Voluntary sector organisations often collate a wide range of both quantitative and qualitative data, relating to service provision and the needs of service users. This data can be very useful in informing the JSNA process. In particular, information relating to mens use of services, male service users needs is useful. The collection of gender disaggregated data is also important in helping to inform the commissioning of gender sensitive services and should be fed into the JSNA process if available. I Voluntary sector organisations often operate at the heart of communities and are well placed to ensure that the voice of marginalised groups are heard and understood. For example, the needs of marginalised and hard to reach groups of men are very relevant here. I Voluntary sector organisations are also well placed to understand the gaps in service provision within their local community. I Voluntary sector organisations can play a key role in designing innovative services to fill these gaps in provision, to achieve better health outcomes for service users

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Catherine Yeulet / istockphoto.com

Benefits for the voluntary sector organisations in engaging with the JSNA process
There are many benefits for voluntary sector organisations who involve themselves in the JSNA process. One of the key benefits is the influence that can be brought to bear on commissioning and planning of service delivery, to reflect the needs of local service users. Other benefits include: gathering information to help to understand the market and needs of service users. This can help organisations in designing new services relevant to local needs, when these come up for tender.

How to get involved?

The first step is to find out who is leading the JSNA in your area and contact them to find out how they are engaging with the voluntary sector I Volunteer to use the data gathered by your organisation about the service users you work with, local needs and service provision to inform the JSNA process. Consider how your own services address local needs. I Think about the current gaps in service provision from your own experience and the experiences of staff and service users. Consider the new types of services that could be designed to fill this gap, and whether your organisation is in a position to provide this service if commissioned. I Discuss with staff and service users whether there are other available means of contributing to the JSNA process e.g. local service user health forums. Consider who is best in your organisation to act as a main contact with the JSNA lead for the area and how the relationship will be managed.

Equality Delivery System

The Equality Delivery System is another mechanism that can be used by voluntary sector organisations to hold statutory organisations to account to meet the requirements of the Equality Act (2010). Background The Equality Delivery System (EDS) is a tool developed for current and emerging NHS organisations to review and rate their equality performance with staff, patients and the public. Its focus is on People not Processes. The EDS was developed by the NHS Equality and Diversity Council, which is chaired by Sir David Nicholson and is a sub-committee of the NHS Commissioning Board. The EDS offers voluntary and community organisations an opportunity to help to progress the addressing of equalities and the tackling of health inequalities. This is particularly relevant for addressing the health inequalities experienced by men. Why it is needed The Equality and Diversity Council has prioritised the EDS as the best means of helping the NHS as a whole to improve its equality performance. Despite much good practice, there is considerable evidence that some patients and communities may not be as well served by the NHS as they should be. The EDS covers all nine protected characteristics in the Equality Act 2010.

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The EDS: How it works

Commissioners and Organisations are expected to identify local interests, assemble local evidence (JSNAs, Surveys), agree roles with National and Regional bodies and to then analyse their performance against the 18 outcomes. A grade will then be jointly agreed and priority actions will be selected for each objective. Priority actions should then be integrated into mainstream business and the grades/actions will be published locally and shared with Health and Wellbeing Boards whereby any serious concerns will be alerted to the CQC. There is clearly a role for the VCS in all these parts of the process. Performance is analysed against 18 outcomes that are grouped into four objectives: 1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership Grades and priority actions should be published locally in Annual Reports, Quality Accounts and in other ways accessible to local interests. The grades and priority actions should be shared with health & wellbeing boards for comment. CQC should be notified of particular concerns about providers, for possible inclusion on organisations Quality & Risk Profiles, and potential action. (Once they are established, the NHS Commissioning Board and NHS Trust Development Authority will determine how they are assured of commissioners and providers performance in due course.)

What effective implementation of the EDS looks like

Engagement with local interests including patients, communities, staff, staff side and local voluntary organisations (Step 1), the use of robust evidence (Step 2), and partnership working with local authorities (Step 3) lay the foundations for effective EDS implementation. These three steps can be worked simultaneously. Organisations should work on the steps in such a way that by 6 April 2012, they have agreed their Equality Objectives and related priority actions with local interests, and are ready to work on them.

Who does it apply to?

The EDS has been developed for use in the current NHS and the proposed new NHS as detailed in the Health and Social Care Bill 2011. PCTs and SHAs will be encouraged to use it, as will those involved in clinical commissioning groups, as well as VCS, private and independent providers of NHS services.

What the EDS delivers

The EDS provides a national standard for organisations to work towards. It helps organisations to address health inequalities by enabling them to identify those most in need in local areas. It helps the NHS comply with the Public sector equality duty and it aligns with other NHS systems (NHS Constitution and the NHS Outcomes framework) to make joined up working easier. By providing a national equalities tool for local use, the EDS will lead to greater consistency, transparency and greater sharing of good practice across the NHS.

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What role can the voluntary and community sector play in the EDS?
Social class, poverty and deprivation are often closely related to the incidence of ill-health and the take-up of treatment. In addition, many people from protected groups are challenged by these factors, and as a result experience difficulties in accessing, using and working in the NHS. For this reason, work in support of protected groups is best located in work to address health inequalities in general, with a focus on improving performance across the board and reducing gaps between groups and communities. The voluntary and community sector have been involved in the development of the EDS. It is expected that the continued involvement of the voluntary and community sector (VCS) in the roll out and rating phases will be integral to the successful implementation of the strategy at local level. There are several ways in which the VCS can be involved. Facilitating local engagement and implementation of the EDS The 2nd and 3rd tier VCS could have an important role to play facilitating engagement, enabling providers from all sectors to successfully implement the EDS. VCS support for organisations Whilst there is no official support framework in place, it is envisaged that providers will need to liaise with a number of VCS groups in their local area to fulfil their statutory duties and to tackle health inequalities head-on. VCS support for patients and the wider public Wider VCS will be able to help patients and the public to understand more intricate permeations of an organisations performance, the reasons why they are at a particular grade and how they need to improve. VCS interaction with local and national health infrastructure and Local Authorities VCS providers will need to build these relationships in terms of working through the EDS process.

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Christopher Futcher / istockphoto.com

Further sources of information

The MHF website: www.menshealthforum.org.uk More information about the Mens Health Forums mini manuals and other health promotion materials: www.menshealthforum.org.uk/mini-manuals/19009-mens-health-forum-mini-manuals Male Health www.malehealth.co.uk NHS Choices www.nhs.uk Good reliable health information from the NHS Man MOT http://manmot.co.uk/ This is the first online surgery directed at men. It is sponsored by Pfizer and provides free confidential online consultations for men. Free support and advice www.patient.co.uk This site provides free support and advice about a range of medical conditions Change for Life www.nhs.uk/Change4Life/Pages/change-for-life.aspx The Change for Life site offers free advice and information on adopting a healthier lifestyle

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The Mens Health Forum 32-36 Loman Street London SE1 0EH Tel: 020 7922 7908 Fax: 020 7922 7706 Email: office@menshealthforum.org.uk

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Published: November 2011. Design: goodthinkingcommunications.net Registered office as above. A registered charity (No.1087375). A company limited by guarantee (No. 4142349 England)
Front cover photographs: Christian Baitg / istockphoto.com